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Norman Pastorek, MD Dr. Byrd: The first patient is a 23-year-old woman who underwent two prior open rhinoplasties to correct a prominent dorsum and bulbous tip; the last procedure was 1.5 years ago (). She had no septal work performed, and her septum is completely intact. She feels that her tip is worse now than it was before her surgeries. Specifically, she complains that just cephalad to the tip-defining points, the supratip area has gotten broader and firmer. She thinks that in her frontal view her infratip lobule area is “just hanging.” She has some dorsal irregularities that she does not like; she thinks her nose “caves in” on the right and has a “bulb” at the keystone area.
Constantian, how would you help her? This 23-year-old woman had 2 open rhinoplasties to correct a prominent dorsum and bulbous tip.
She now wants refinement of her dorsum and tip. No septal work has been done. Constantian: What is important is that it is a long nose, and you cannot reduce support and yet expect the skin sleeve to maintain a shortened position. The patient has obvious nasal deformities, but I would maintain increased support wherever possible to make the nose shorter.
She has lateral crural malposition; the crura are rotated superiorly. The axis of the lateral crus, which is very convex, goes toward the medial canthus, and that is why prior reductions have not helped.
You have to reposition the lateral crura to get rid of the convexities, and the alar hollows below them. This would also improve nostril rim contour.
Finally, it looks as if the middle vault is collapsed. My approach, since she has septum, would be to widely skeletonize over the middle vault and, more narrowly, over the dorsum. I would do this closed, as I do all rhinoplasties. I need to hold my grafts in position, but I want to make this nose shorter.
After wide skeletonization, I would shorten the caudal septum and caudal ends of the upper lateral cartilages to get the base into better position. The dorsum will look even lower than it does now after the base is rotated. Then I would dissect the lateral crura free from their external skin and vestibular skin attachments through incisions (perhaps 3 mm above the rim on each side) and remove them, flatten each crus, then trim it to a good size (6 to 8 mm wide and probably 15 to 18 mm long), and place it back along the alar rim. I would make my access incision where the caudal edge of the lateral crus ought to be, not where it is (). If you perform the surgery open, the important point with malpositioned (cephalically rotated) lateral crura is to make the diagnosis before surgery. Once the nose is open, every lateral crus will look misleadingly orthotopic. After the lateral crura are replaced, I would perform my septoplasty for airway and graft material.
A, Intraoperative view of a 30-year-old patient undergoing secondary rhinoplasty in whom the distorted and malpositioned lateral crus has been dissected free and resected. Note that despite a prior rhinoplasty, most of the crus can still be recovered. This is typical. B, Crus after flattening and trimming; it will be replaced along the rim to support the external valve. I need something to straighten the dorsum. Ideally, if there is enough septal cartilage, I would first use spreader grafts for symmetry. If I cannot use bilateral spreader grafts, I would at least put one on the right, which is the concave side.
If I also have a piece that is curved, then I can put it in on the left with the convexity facing toward the right. Frequently, a spreader graft on the convex side will move the septal partition over, but you have to look at it. Medieval 2 Total War Gold Edition Mac. Sometimes it does not do anything except make the nose wider; in that case, I would only insert the one on the right. I would use a dorsal graft that is long enough to extend from where the root ought to be, which is roughly the upper lash margin, down into the supratip area (if I get a nice straight piece).
Any tip grafts in this patient would have to be very soft because she has thin skin, and the middle crural segment that remains will still be fairly strong, so increased projection is not necessary. I would use two, three, or four pieces of very soft cartilage, and they must be completely invisible at surgery, just enough to make the tip symmetrical. She has support added in the middle third and dorsum, and a little bit in the tip, and so the shortening will persist. The airway should be better because the middle vault is supported, particularly on the right, and the external valves are better supported because the lateral crura are in position. Patients like this have at least twice the mean postoperative airflow. I know this from our 600-patient rhinomanometry series. Byrd: Where exactly are you dividing or resecting the lateral crus relative to the domes?